Drug War Chronicle Book Review: "Over the Influence: The Harm Reduction Guide to Managing Drugs and Alcohol," by Patt Denning, Jeanne Little, and Adina Glickman (2004, Guilford Press, 328 pp., $16.95 PB)

Phillip S. Smith, Writer/Editor

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We usually reserve this space for books hot off the press, but in the case of "Over the Influence," we make an exception. This book is special enough for us to make it a premium for our contributors, and given that we are publishing a story this week about the rapidly rising toll from drug overdoses, we think its importance is self-evident.

Like most people interested in drug law reform, I believe that substance use is a constant in human affairs, and that -- as US history over the past few decades demonstrates -- nothing short of totalitarianism can stomp it out, and then, most likely, only temporarily. I also believe that substance use does not automatically equate to substance abuse or addiction.

Nor am I especially comfortable with the "disease model" of addiction championed by the mad scientists of NIDA, as well as too many well-meaning drug reformers and, perhaps, self-interested drug treatment providers. The concomitant to the disease model, which seeks to replace human agency with biopsychopharmacological determinism, is the Alcoholics Anonymous-based drug treatment dogma that people with problematic drug habits are addicts, the victims of a progressive, incurable disease whose only cure is lifelong abstinence.

As the authors of "Over the Influence" note, philosophical objections aside, a major, major problem with abstinence-based drug treatment is that it just doesn't work. Although abstinence-based programs account for more than nine out of ten programs in the US, that appears to be more because of inertia than results: Such programs, which define "success" as abstinence from all drugs, work only between 5% and 39% of the time, and that's for the small minority of users who actually complete them.

Instead of relying on programs and models that rely on the disease model and the insistence that the only success is staying completely straight, the authors of "Over the Influence" suggest that we apply the principles of harm reduction to drug use in our personal lives. While the notion of harm reduction in this context is controversial, it shouldn't be -- because it's only common sense.

Harm reduction accepts that people may do things that pose potential risks or harms to them and -- duh -- seeks to reduce those harms. Some people like to race automobiles. Abstinence says they should never race; harm reduction says they should wear helmets and protective clothing. Some people (like those darned teenagers) like to have sex without waiting for marriage. Abstinence says they should remain virgins until the holy day arrives; harm reduction says provide them with birth control and protection from disease if they're going to be sexually active.

When it comes to substance use, the advocates of abstinence are even more insistent: The only way to cure the disease is to never use any psychoactive substance (except for cigarettes and coffee, as any AA veteran knows). But Denning, Little, and Glickman, all three of whom have long experience in harm reduction and therapy under their belts, dare to suggest what has heretofore been anathema in the treatment community: There are other choices besides quitting. In fact, they take as their mantra a slogan popularized by the Chicago Recovery Alliance: Any Positive Change.

What does that mean? Say you think your cocaine use is getting out of hand. You had been snorting only on weekends, but now you find yourself doing it every day. Can you at least skip Tuesday and Thursdays? If you manage to do that, you have not only reduced the potential harm of chronic cocaine use, you have also proven to yourself that you can control your relationship with your drug of choice, that you are not a helpless victim doomed to a downward spiral of addiction and misery.

Or maybe you like to drink, but you find that your nightly bottle of wine is making you so sluggish the next day that you are not getting your work done and your job could be in jeopardy. Can you make it a half-bottle? If so, once again, you have reduced the harm of your substance use and you have demonstrated your control over your own life. And you have not given up the fruit of the vine, only moderated your use of it.

Of course, not everyone is just going to wake up one day, decide to change their substance use habits, and be successful at it. But even if one does not succeed on the first try, the very act of trying to assess and regulate one's drug use is a step in the direction of harm reduction. One of the elements that makes "Over the Influence" so useful for drug users (and those concerned about them) is that it shows readers how to think critically about their drug use, its benefits, and its potential harms. A little introspection never hurt anybody, and when it comes to potentially lethal substances like alcohol or hard drugs, a little introspection can save lives.

"Over the Influence" is absolutely essential for anyone seeking to come to grips with his or her substance use, and even more so for those friends or family members of people who are having problems with their drug use. Unlike AA-based abstinence programs, which seem to work for only a small percentage of people, applying the principles of harm reduction to substance use is likely to make a difference in the larger world of still-drug-using people.

It seems so sensible. How can this be controversial?

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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